多模式神经电生理监测在椎管内占位手术中的应用

Multiple intraoperative monitoring of neuroelectrophysiology in surgical treatment for intraspinal occupying lesion

目的探讨体感诱发电位(CSEP)、经颅电刺激运动诱发电位(TES-MEP)与自由及激发肌电图(EMG)多模式联合监测技术在脊柱椎管内占位手术中应用的价值。方法对47例脊柱椎管内占位患者(颈椎4例,胸椎14例,胸腰段13例,腰椎13例,骶椎3例)行占位病变切除术中采用CSEP+TESMEP+自由EMG+激发EMG监护。结果 (1)CSEP和TES-MEP:监测成功率各为100%和93.6%;阳性率分别为19.1%和17.0%;联合监测假阴性率及假阳性率均为0%;10例诱发电位阳性均与手术操作有关,8例及时报警采取措施后渐恢复,2例MEP阳性未能恢复,术后肌力下降;6例CSEP改善,术后症状好转。(2)自由和激发EMG:34例患者术中出现自由EMG,其中1例马尾神经严密包裹病变的患者,术后小便功能异常,术后渐恢复。结论 (1)椎管内占位术中联合运用CSEP和TES-MEP监测,排除各种干扰因素后,能准确地反映术中脊髓功能状况;(2)术中自由及激发EMG监测可准确探查和鉴别占位病变神经组织分布,实时反映神经受激惹情况,预防医源性神经损伤。

Objective To investigate the efficacy of combined monitoring of motor evoked potentials withtrans-cranial electrical stimulation （TES-MEP）, somatosensory evoked potentials（SEP）, free and tirgger EMG for surgical treatment forintraspinal occupancy surgery occupying lesion. Method Combined SEP, TES-MEP, free and trigger EMG monitoring were employed in forty-two cases of surgical treatment forintraspinal occupancy surgery occupying lesion, including one cervicalcase, fourteen thoracic cases, thirteen thoracolumbar cases, eleven lumbar cases, and three sacral cases. SEP and TES-MEP were used to monitor the precise status of sensory and motor pathways in spinal cord. Free and trigger EMG responses were used to more accurately explore and distinguish distribution of nerve tissues in and around theintraspinal occupancy.All cases were performed after surgery. Results ①SEPwas successfully achieved in 47（100%） cases. TES-MEP was successfully achieved in 44（93.6%）cases. Combined motor and sensorymonitoring was successfully achieved in 44（93.6%）cases. The abnormality of SEP was observedin 10 cases（19.1%）, while the abnormality of MEP was observed in eight cases（17.0%）. False negative and positiverate were 0% with combined SEP and TES-MEP monitoring. 10 positive cases of evoked potential were all caused by operations. Eight of them recovered gradually after the alarm in time to take measures. The other two cases who were only positive in TES-MEP failed to recover and postoperative muscle strength decreased. The symptoms were alleviated in six cases with SEP waveforms getting better. ②34 cases of EMG？response was observed. Postoperative urination dysfunction occurred in one case in which the intraspinal lesion was wrapped by tight cauda equina. However, this patient recovered in the twelfth day after operation. Conclusions ①During surgical treatment for intraspinal occupancy surgery occupying lesion,combined application of SEP and TES-MEP can reflect the physiological and pathological conditions of spinal cord after ruling out the interfering factors, and improve the monitoring effect .②Intraoperative monitoring of free and trigger EMG can not only accuratelyexplore and distinguish distribution of nerve tissues in and around the intraspinal occupancy, but also respond to the nerve irritation timely, and prevent iatrogenic nerve injuries.